Dr. Tishler is a Cannabis Specialist. Through his training in Internal Medicine and years of practice as an Emergency Physician, Dr. Tishler brings his knowledge, reason, and caring to patients here at inhaleMD, and through his advocacy work at the local and national levels.

Dr. Tishler graduated from both Harvard College and Harvard Medical School, trained at the Brigham and Women’s Hospital, and has spent many years working with the underserved, particularly our Veterans. Having treated countless patients harmed by alcohol and drugs, his observation that he had never seen a cannabis overdose lead Dr. Tishler to delve deeply into the science of cannabis safety and treatment.

Dr. Tishler is also a parallel entrepreneur working for patients’ wellbeing in the corporate space, helping to elevate dosing and safety profiles of medication, and helping to establish best practice for bringing new Cannabis products to market.

Dr. Tishler is a frequent speaker and author on a variety of topics related to the medical applications of cannabis. He is the President of the Association of Cannabis Specialists, and the Treasurer and a Board of Directors member of Doctors for Cannabis Regulation (DFCR).

[00:00:00] All right welcome everyone. Others are called. I'm your host for thinking outside the bud. We are here with Dr. Jordan Tishler.

[00:00:08] Welcome. Thank you for having me on. It's a pleasure.

[00:00:10] So a couple things about Dr. Teschler just some background. So Canada specialist so a lot of time in cannabis originally an interim medicine emergency room physician really kind of looking at application of cannabis in the medical space and that's where we're going to talk to today. Dr. Teschler graduate of Harvard College and Harvard Medical School trained at Brigham and Women's Hospital.

[00:00:32] I want to say women.

[00:00:33] All right I'm not going to get a book and spent a lot of time working with the under served and actually a lot of our veterans as well. Curious to hear about that and has experience working with basal patients that have seen side effects downsides of alcohol and drugs and looking at cannabis as an alternative is that understanding how cannabis works.

[00:00:52] From a medical point of view looking at safety looking at treatment looking at dosing. So we're going to talk about that today and has also been onto our entrepreneurial corporate side looking at how to bring in medical cannabis from a business point of view and taking cannabis product to market.

[00:01:08] Dr. Teschler is also president of the Association of cannabis specialists inus the Treasurer and a board member of the Board of Director member for doctors for cannabis regulation Dieter C.R.. Again thank you for being on the program. I'm

[00:01:23] Really upset about this because I think this whole medical recreational sort of bifurcation of the industry is a fascinating one and really kind of understanding it and what's driving each side.

[00:01:35] Why don't we start there. Why don't you give us kind of a frame from your point of view of what what these two terms mean right now how they can impact how the industry is set up to help set up the discussion a little bit.

[00:01:46] Sure. I think you know it's a very interesting dichotomy but in some ways it's rooted in some interesting history. So you know without getting into too much of the detail about why cannabis was made illegal for all sorts of nonmedical reasons what sort of came about was through the AIDS epidemic in the 80s and early 90s. The observation that patients could be helped by cannibals and so there was this idea that evolved medical cannabis and as you know in 1996 California became the first state to go against the federal government and legalize cannabis in a medical context. But they didn't really get into any of the sort of medical details that just sort of said look if we're going to go against the feds we're going to just kind of make it a very passive thing where the doctor's role will simply be to say yes or no this is OK for you or good for you. I mean technically what you're supposed to be saying is saying that the benefits likely outweigh the risks and that's where the end of the doctor's involvement. And then out the patient would go into the wide world and try to sort of figure out how to do all of this. And that is in my opinion and I think the opinion of most other practitioners not particularly medical approach to anything. What I often say is look if you went to your doctor and said Hey Doc I'm worried that I have high blood pressure or some other illness and the doc said yup you've got high blood pressure. Go get some medicine. You'd stop and you'd see that they had three heads right.

[00:03:19] You'd be like well what Edison and where should I go to get it. And how much do I take. And what is it going to do for me and what are the side effects and all of those sorts of questions that we would expect any competent clinician to provide answers for. So we need to kind of get back to that level of involvement for physicians to truly medicalized this and there are a number of forces out there that are sort of arrayed against that idea because Azen sort of initially I think unintended consequence of this medical stuff we started to see people who might need more appropriately termed recreational users finding sort of minor maladies by which they could then qualify under the record under the medical law to to get their cannabis. And so it developed over time from being a treatment for some very very seriously ill folks into this sort of wink wink nudge nudge thing. I'll tell you a little story. Several years ago I was walking the boardwalk at Venice Beach in California with my wife and young daughter and a very attractive woman rollerblade it up to me wearing nothing other than the tiniest string bikini covered with pot leaves. And she said do you want a medical card. I can get you one in five minutes and I'm just dumbfounded right because I'm doing this. But seriously. And I'm standing there with my 10 year old daughter thinking really. This is a medical. So you know we need to get away from that sort of thing. And now that we've moved into an era where medical and recreational sort of coexist at least in many states there is a lot of money at play.

[00:04:59] That's really trying to shift the focus to recreational and shift the idea that medical medical into his being sort of a quasi recreational thing with this idea that you just if you have a back ache or whatever go down your local pot shop and somebody behind the counter will tell you what to do. But of course they're really talking out of school right. And the guys behind the counter know bout as much about medicine as your average Starbucks barista. So you know if it turns out that your back pain is because you had an undiagnosed you know prostate cancer you're going to be in a world of trouble if you have just gotten your advice from the bud tenders so I think you'd like to avoid that situation. But again there's a lot of money at stake here because the more they can push people into that arena the more money they can sell by selling more and more cannabis. And frankly unfortunately the states governments have sort of acquiesced to both medical and then recreational sort of around this buzz about look at how much tax revenue that we can generate. And that's really in some ways really driven the train where the for the legislators. And the problem is then they want to make everybody a recreational patient because we don't tax people's medicine. But then that also means we're forcing or trying to encourage people into a market that isn't suited to their needs.

[00:06:20] Yeah. And I think it is good that they get ear ear pointing out not just the differences between the markets but how they impact each other. And I think that's really the point here is that it's Itaú how you define one market will really end up changing the forces. And I think the taxation is a really interesting point that really frames it differently for legislature for governments for tax revenues. So I guess in terms of from the medical side when you say or when we talk about trying to bring in better regulation what does that look like like what kind of structure or what kind of standards what kind of processes do you feel are really going to help help that side of the cannabis market.

[00:07:01] It's a great question. You know one of the great ironies in all of this sort of the legal regulatory framing is that we say OK we're not going to tax people's medication. And that's correct. We shouldn't be. But the irony to me is it is probably fairly meaningless in the long run because at least my patients use very little cannabis right. In fact there's this concept that a patient needs more or higher potency cannabis which in fact couldn't be further from the truth. My patients tend to use this stuff very cautiously and carefully and in very sparing amounts and they get great benefits. It's the recreational users who want to use more and different and new and high doses so they would be the ones who would save a significant amount of money if they were in the medical system. But then of course they shouldn't be in the medical system. So when we start to talk about what kinds of regulations would really make an impact. I think we need to really focus on safety but that's across both markets. Right. What we also really need to focus on and I actually think this is across both markets as well is this idea that the bud tenders really don't know medicine. So if you are going into a recreational shop and you want to have a discussion with the bartender about you know the type of high that you're going to get or how you're going to get stoned over the weekend or you want a particular flavor of ADD aboral those sorts of things that are sort of about what recreational is about which is you know having fun.

[00:08:28] First of all I don't have any problem with that. And I think that's a legitimate conversation with the bartender. They know something about selling cannabis and what products might be enjoyable to you. But again if you're going in there saying I have anxiety or I have depression or I have a backache or or any of those sorts of things I think we'd have to get to a point where the bartenders know enough to know that they shouldn't be addressing those questions. And if you go into CBS or a mile where you are Duane Reed and say to the cashier what should I buy for my back pain. He or she is going to simply say I can't answer that question. You need to talk to the pharmacist because there are strict regulations around who can say what in a pharmacy and the pharmacist Mace is probably going to say to that question you need to talk to your doctor or you could try some Advil for a few days but if not then you should talk to your doctor. Because this system has evolved over the last hundred years in response to various problems and situations so that we now have a tightly regulated and well functioning system. And one of the odd things about the politics of all this is that because the federal government resists the idea that cannabis is medicine we've had to invent these sort of state by state systems that are reinventing the wheel and frankly aren't very far along with it so they're not very good at it.

[00:09:53] Ideal in my mind would be to go back through the system that has been evolved carefully over the last years and say look you know we don't need to reinvent this we just need to change the politics of the situation and just kind of push for regulation because basically we're coming back to regulating and putting in place these practices and standards that are at a federal level so that we can actually have consistency.

[00:10:16] Absolutely. You know and this is a major focus for me at this point.

[00:10:20] And so yeah I guess the the model and I'm sure it's a perfect analogy but the one I use as kind of fitness and working out in physiotherapy.

[00:10:29] I mean there's the you know if you want to if you just want to go to the gym and work out you need to hire any trainer you know that that is fun and you want to do things but you know if you've got a serious injury and you're looking at rehabilitation you need to go through a very specific diagnosis. You know putting together regime working with someone who is actually a physiotherapist and knows you know a lot more intricately what's going on with the body and how to recondition those parts in the right way in the right process.

[00:10:55] I think that's not a bad analogy. The other point is that you know rehab people have a certain degree of training so that they really know what they're talking about but they also know when they don't know. And so they work as a member of the team in with your primary care doctor where your orthopedic doctor or all the above you know. And this is where I think we need to get here in Massachusetts we have a law which has pluses and minuses. One of the interesting bits is that the doctors such as myself who are doing this are prohibited from having any sort of financial relationship with the dispensaries to whom we send patients. Now that makes a great deal of sense from the point of view of preventing collusion. Right. And so I'm all for it but one of the unintended consequences is that I for example through my practice have figured out what sorts of products my patients need and what sort of approach to taking care of them they would need. And ironically I can't turn around and work with the dispensaries to develop appropriate products because that would violate the law. So we're having to find some interesting ways to bestow that knowledge upon the dispensaries in a way that doesn't transgress either the spirit or the facts of that law. And it's you know it's really just kind of about taking time my knowledge for example and putting it in do into a group where it's sort of at arm's length from the get scrubbed.

[00:12:27] Yeah exactly.

[00:12:28] And I had I hadn't realized that because of the you know not noninterest non collusion function or structure of the regulation that it actually creates a kind of a knowledge gap or a knowledge block where people that are developing a you know the cannabis the thc cbd those products that they can't actually work with you directly because of those issues.

[00:12:49] Exactly. And so they are really you know what they do is they end up either kind of winging it or they hire a consultant usually from out west Florida who brings with them a certain maybe looser model then at least I would be looking for. You know there's a there's a dispensary here that made cannabis barbecue sauce. And you know and the irony is that this is a dispensary that is run by a physician. And I I said to her what's up with that. You said Oh the guys in the kitchen were having some fun. And now I can understand that but when I asked more specifically from the development people there they said look we're we're polling our clients and asking them what they want. Well that would make sense if you had a homogeneous group of patients but when you have a group of folks who are a mixture of patients and shall we say recreational users who have a card then you end up with kind of a mixed message and you end up with developing products that are far more recreationally oriented than medically. And then when I as the physician say is my patient you know where do you live where's your local dispensary and they say all wards near that one I'm like well you can't go there because they don't have the right kind of product for you. You know there is another dispensary. I mean that one I just mentioned with the barbecue sauce actually has some very good products it's just that what a weirdo. But then there's another one in town where their idea of products are mac and cheese spaghetti and meatballs pizza in fact they managed to get an article in The New York Times about this week pizza. And then I wrote an op ed in response saying you know we pizza is not medicine and of course nobody wanted to publish that.

[00:14:34] Well let's talk about the kind of the the the the the medical products side the good when we talk about medical products what what forms what formats what delivery mechanisms are used.

[00:14:46] Are you looking at are out there right now are being developed.

[00:14:50] You know one of the issues again is that because the federal government isn't involved there's barely a sense of need for safety. To some degree that gets dealt with at the state regulatory level but that's really as far as it goes. There's really no discussion about well two things. One is called bioavailability right which is you know if you take this medicine in some form does it actually even get into your body. And a great example of that would be you know Tom Pickles and patches where in fact generally speaking they don't go through your skin at all. So they're a great placebo but if you actually measure blood levels you find there aren't any. So there's that issue and then the larger issue the sort of FDA level issue is efficacy. Right. Not only does it get into your body but does it actually do something new something better than a placebo would do. And there's almost no discussion of that. There's beginning to be but that's really where we need to go. I think one of the issues for the industry is that in the absence of needing that level Kruth basically hit everybody has said look if there's a hole or a surface we're going to put cannabis there right. So so we've got cannabis lotions and cannabis patches and Kamis suppositories and cannabis that gentles depositories and tinctures and vaporising and the list goes on and on.

[00:16:16] You know again if you wanna go and buy a bottle of cannabis you know soda water you know for fun. The my. But let's not pretend that that's a medical approach. So you know but the flip side of that is that things that are medical are distinctly less sexy. You're right. I mean you know if you're coming at this from a recreational point of view and somebody says choose between a weed pizza or a weed capsule you're probably going to choose the pizza cause it just sounds like more fun. On the other hand if you are an 85 year old lady with multiple medical issues and you have extreme back pain you know and you're unlikely to be interested in that pizza. And so really you know the question is how do you enter the medical market as a product manufacturer and do well. When right at the moment everybody's talking about the sexy products not the sort of you know medicinal accurate sort of boring like you know no fun at a party kind of stuff you know. So I think that we need and ultimately will differentiate that because of course most people are getting older and unfortunately sicker so that there is going to be more and more demand for products that actually work and take care of people and probably less demand after a certain you know ramp up for a week.

[00:17:42] Do you think looking at the kind of the market is do you think the way that this is going to play out is that you'll have more of a bifurcation of these markets.

[00:17:50] You know a little more formal specific medical obligation that will have its process.

[00:17:55] It's sort of dispensed prescribing dispensing using model and that a recreational market while it will have is.

[00:18:03] I think that's probably what will happen. I mean if things go the way I want them to that's what would happen. Yeah I mean ultimately I think that whether the federal government in the near term decides to legalize for recreational purposes and make a unified national policy or continue to sort of permit and otherwise ignore state by state legalization. I don't know and you know I would think in that in the broadest sense I would like to see it become a national policy because I think national policies are a good thing. But in the shorter term I think we need to get a national policy around medical that provides for that efficacy in the specifics and basically we need to have a prescribing system. The number of times per week that a patient of mine goes to the dispensary with a very specific set of recommendations by me only to have somebody at the dispensary sort of twist their arm and get them to do something else and then call me back and say Well doc it didn't work or Doc I feel sick or something like that. And I said well what do you do. And they say well you know the blood Tender's said and I'm like well I'm sorry but that's why I told you not to listen to them about this. So you know one of the things that's really interesting and I only learned this and he got into this field even after years in sort of medicine in the broader sense is that I think that most people look at a prescription as a way of the doctor sort of manipulating them write the prescription they think is there to tell them how to do it and you know to some degree that's true.

[00:19:34] That is to say it's a way of communicating. I want you to take one pill twice a day. But really I think at the core of the development of the prescription model is really about trying to control the seller right. Why is it that CBS or Duane Reed when you go in for your blood pressure medicine doesn't say wink wink hey would you like a side of Percocet with that. It's because they're not allowed to. Not because they wouldn't want to sell you the Percocet right. So the law and the prescribing system has really evolved to protect the patient against sort of predatory business practices. And again because we're reinventing everything in the world of cannabis we haven't gotten to the point where there's any ability to hold the dispensaries responsible for doing the right thing medically speaking. We've got to get there. So I think know that's going to require the federal government to come back in and say you know this is medicine so we should be doing this right.

[00:20:29] And we're so you know so we have this situation the situation we've got the state by state kind of laws being passed. What what do you what do you think needs to happen or what do you think the dominoes are going to be in terms of the the federal side. Do you have any insight or thoughts on how you think it should play out from kind of a safety prescribing point of view or do you think it's going to play out based on how you see the conversations go.

[00:20:55] One of the things that I think is interesting is that some of the states have gotten bits and pieces of this equation. Right. And and then typically blown other parts of the equation. So for example Massachusetts like many states has a list of acceptable conditions. But what they also did was then they followed the list of acceptable conditions with a line that said basically or any other severe conditions that are determined by your physician. So that takes the doctor out of the role of being sort of this chimpanzee saying yes you have something that's on this list and actually applying the knowledge and experience that we have worked so hard to garner and to be able to take care of patients you know with a range of illnesses that sort of need that level of severity and debilitation. So I think that's a really good thing. On the other hand Massachusetts set a limit on the cannabis amount at 10 ounces every two months which is an astounding amount of cannabis.

[00:21:53] And frankly I tell all of my I was just doing the calculation in my mind. Right.

[00:21:59] Well you know an ounce is basically a Ziploc bag stuffed full. Right. So Tanev those every two months this is a huge amount. And oddly enough the system is set up so that I can override the system upwards but not downwards which is really kind of a weird legal thing but you know I tell my patients most of my patients use something closer to an eighth of an ounce in a month. A few of them are a little heavier users and I'm basically tell anybody look if you get near an ounce a month we're going to have a conversation but this doesn't always mean it's inappropriate use. It just means that that's enough that I think we need to figure out what's going on there. So Massachusetts like I said got some pieces right. Some pieces not so right. Florida is another great example where they actually have a medical order you know. So the physician puts in I want you to get this product and use it like this. And I think that's a great idea. They've blown some other aspects of it. So what we kind of need at the federal level to get back to your question is we kind of need the greatest hits of and we're you know I started this organization called the Association of cannabis specialists.

[00:23:03] We're now an international organization of doctors and other clinicians who try to take cannabis medicine seriously and want to yell evade the standard of care and make sure that we have the tools available to take proper care of patients. And so we're working on developing this kind of a rubric that is this greatest hits and then presenting it to the federal government in the United States as well as other places. And I think you know the government is sort of wending its way around to thinking about. I don't think they're there yet. I think that there are you know there's sort of a very interesting sort of political set of dynamics I think you know on the left side which is the side that I tend to associate myself with. We have people whose point of view tends to be you know we should be legalizing this because of the social justice aspect of things but aren't really giving any thought to patient care. And you know there are folks out there like Cory Booker and Kamala Harris and Rokan who I absolutely support. But in their discussions there is no discussion of what we should be doing to protect.

[00:24:10] And to treat the patients. And you know people of color or also patients so we kind of think that brought more broadly about that on the right. There is this kind of weird tug of war between sort of the pro business aspect and the pro states rights aspect and the law and order aspect. So you know the state's right guy and the business guys are sort of going yeah let's do Canibus somehow not necessarily listed in medicine particularly but then there's the law and order guys were out there sort of saying well wait a minute we just for hippies and we can't have that sort of the Nixon argument. And you know it's evolving and I think that people on both sides of the aisle are starting to pay attention and take it seriously and I think that's a great thing. You know I work with with a group in Washington. And what they keep saying to me is we need to work on the conservative folk you know and if we can get those people to pay attention to this and to understand the validity of it then we can probably start to move the ball.

[00:25:12] Yeah it is. It is. If I was in Boston I would say it's a wicked problem.

[00:25:18] You know there's there's lots of different facets. I mean I do think the more you know the more conversation the more kind of getting the right people together to kind of figure out really what are the dynamics and how do we put smart kind of policies and processes in place make sense. This was great we're hitting time here. So I think we learned a lot. I think this is really fascinating. If people have more information or want more information about either the Association of Canada specialists or the doctors for cannabis regulation what's the best way to contact you. Get a hold of you. Learn more about some of the work you're doing with those organizations.

[00:25:51] So the association of cannabis specialists is cannabis hyphen specialist dot org and you can spell that with specialist with or without a terminal. There it works. So again cannabis hyphen specialist dot org. Doctors for cannabis regulation which is really an anti prohibition group are not really focused on medical but focused on social harms. They're at D.F. see our dot org and then anybody who's interested in getting in touch with me specifically around medical staff can come through my Web site which is inhale M.D dot com and then you can actually you know put in an email right there in that land right on my desk.

[00:26:32] Awesome.

[00:26:33] And I will put up all these links and the Urals and the e-mail address and the show notes so people can get all of it. They're

[00:26:41] Fantastic. Thank goodness was a pleasure. Thank you so much for taking the time today. Thank you. My pleasure.